Should people with chronic respiratory health problems stop taking long term oral immunosuppressants?
March 30, 2020
Dr Asli Kalin
School of Primary Care Research Fellow
On behalf of the Oxford COVID-19 Evidence Service Team
Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences
University of Oxford
Correspondence to firstname.lastname@example.org
Evidence of how to manage people with chronic lung conditions on long term oral immunosuppression during the Covid-19 pandemic is very limited. There is no evidence to suggest that long-term immunosuppression should be stopped during the current pandemic.
Patients who use oral immunosuppressive medications may be at higher risk of severe bacterial or viral infections. Whether people with chronic respiratory health problems on long term immunosuppression are at increased risk of developing severe infection or complications from COVID-19 remains unclear.
Thus, patients may be concerned about continuing to take their medication in light of this perceived risk, and there is a need to balance the risk of stopping medication against any risk of continuing to take it.
This article is specifically about oral long-term immunosuppression in patients with respiratory disease. The British Thoracic Society has also published guidance on the use of short term steroids in asthma and COPD which can be found here. Guidance on the use of inhaled corticosteroids in asthma can be found here.
Chronic lung disease is a risk factor for severe Covid-19 infection
The link between chronic lung disease and severe Covid-19 infections has been widely reported.
A retrospective study looking at clinical characteristics of 113 deceased patients with coronavirus disease 2019 showed the following: out of a total of 274 patients, 18 had an underlying chronic lung condition. Of those, 11 died and 7 recovered.
A systematic review looking of predictive symptoms and comorbidities for severe COVID-19 infection highlighted that COPD is significantly predictive for both severe disease and ITU admission. Our search found no further publications about other types of specific chronic lung diseases and Covid-19 infections.
Patients on long term immunosuppressants should continue those during the Covid-19 pandemic. If patients show signs of infection, long term immunosuppression should be stopped except long term steroids
An article from the Hospital Papa Giovanni XXIII in Bergamo, which is located in the “red zone” of the Italian outbreak and hosts the main paediatric hepatology and liver transplantation centre of Italy, reports that from their experience, immunosuppressed patients are not at increased risk of severe complications compared to the general population, both children and adults. They highlight that unlike common viral agents (such as Adenovirus, Rhinovirus, Norovirus, Influenza, Respiratory Syncytial Virus), Coronaviruses have not shown to cause a more severe disease in immunosuppressed patients. For this family of viruses, the host innate immune response appears the main driver of lung tissue damage during infection.
Whilst our search found no epidemiological data on Covid-19 patients on long term immunosuppression, we found a number of case reports of Covid-19 patients on long term immunosuppression secondary to renal and heart transplant. All report good patient recovery. The usual treatment consisted of low dose prednisolone and by holding off their immunosuppressants when infected with COVID19.
The British Thoracic Society has also published a number of guidelines about various respiratory conditions. The overall recommendation is that patients already established on immunosuppression should keep taking them unless they are experiencing symptoms of infection, monitoring bloods dictate problems or side effects are an issue. The risk being of stopped or reduced their background disease control could slide. Specific guidance can be found for asthma, COPD and interstitial lung disease, including guidance regarding short courses of steroids in acute exacerbations.
Likewise, The British Society of Rheumatology has also published guidance on this subject. If patients develop symptoms of any infection, established practice should be followed and immunosuppressive therapy paused for the duration of the infection and until they feel well, in consultation with their rheumatology team. For those on glucocorticoids, the expectation is that treatment should not be stopped abruptly and advice should be sought from their treating team.
- Patients on long term immunosuppressants should continue those during the Covid-19 pandemic.
- If patients show signs of infection, long term immunosuppression should be stopped except for long term steroids
Disclaimer: the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and social Care. The views are not a substitute for professional medical advice.
Asli Kalin is an academic registrar in general practice and SPCR Fellow.
We searched the TRIP database, Google Scholar, PubMed and the EPPI-Centre’s “Living Map” of COVID-19 papers to identify secondary reviews or guidance, and primary studies that examine the link between immunosuppressive medication and COVID-19, and/or treatment or outcomes of COVID-19 for patients with chronic respiratory conditions. We used search terms to describe immunosuppressants (steroids, cytostatics, monoclonal antibodies) along terms to describe COVID-19 and other respiratory conditions (asthma, COPD and others).
- Chan et al 2020 Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. BMJ
- D’Antiga 2020 Coronaviruses and immunosuppressed patients. The facts during the third epidemic Liver. Transplant
- Chen et al 2020 Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. The Lancet
- Fei et al 2020 First Cases of COVID-19 in Heart Transplantation From China. The journal of Heart and Lung Transplantation
- Jain and Yuan 2020 Systematic review and meta-analysis of predictive symptoms and comorbidities for severe COVID-19 infection. MedRxiv Preprint
- European Centre for Disease Prevention and Control (ECDC). Disease background of COVID-19 [cited 2020 1 March]. Available from: https://www.ecdc.europa.eu/en/2019-ncov-background-disease.